Gender equity and trichiasis surgery in the Vietnam and Tanzania national trachoma control programmes

AIMS

To calculate the gender distribution of trichiasis cases in trachoma communities in Vietnam and Tanzania, and the gender distribution of surgical cases, to determine if women are using surgical services proportional to their needs.

METHODS

Population based data from surveys done in Tanzania and Vietnam as part of the national trachoma control programmes were used to determine the rate of trichiasis by gender in the population. Surgical records provided data on the gender ratio of surgical cases.

RESULTS

The rates of trichiasis in both countries are from 1.4-fold to sixfold higher in females compared to males. In both countries, the female to male rate of surgery was the same or even higher than the female to male rate of trichiasis in the population.

CONCLUSIONS

These data provide assurance of gender equity in the provision and use of trichiasis surgery services in the national programmes of these two countries. Such simple analyses should be used by other programmes to assure gender equity in provision and use of trichiasis surgery services.

Efficacy and safety of atomoxetine in childhood attention-deficit/hyperactivity disorder with comorbid oppositional defiant disorder

OBJECTIVE

To compare the safety and efficacy of atomoxetine, a selective inhibitor of the norepinephrine transporter, versus placebo in Attention-Deficit/Hyperactivity Disorder (ADHD) patients with comorbid Oppositional Defiant Disorder (ODD).

METHODS

A subset analysis of 98 children from two identical, multi-site, double-blind, randomized, placebo-controlled trials involving 9 weeks of treatment with atomoxetine or placebo was conducted. Patients met DSM-IV ADHD criteria. ODD was diagnosed with the Diagnostic Interview for Children and Adolescents-IV (DICA-IV; Reich, Weiner, and Herjanic, 1997). ADHD severity was assessed with the ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHD-RS-IV-Parent:lnv; DuPaul, Power, Anastopoulos, and Reid, 1998); the short version of the Conners' Parent Rating Scales-Revised (CPRS-R:S; Conners, 2000); and the Clinical Global Impressions of ADHD Severity (CGI-ADHD-S; Guy, 1976). Clinical response was defined as a > or = 25% reduction in ADHD-RS-IV-Parent:lnv total score.

RESULTS

ADHD-RS-IV-Parent:lnv, CGI-ADHD-S, and three CPRS-R:S subscale scores improved markedly with atomoxetine treatment. However, a decrease in the CPRS-R:S Oppositional subscore for atomoxetine-treated patients was not significantly greater than scores for placebo-treated patients. Clinical response rates were 65.4% in the atomoxetine group, and 36.4% in the placebo group (p = .007).

CONCLUSION

Atomoxetine was effective for the treatment of ADHD in patients with comorbid ODD. It did not significantly reduce the severity of ODD symptoms, and was well tolerated by the patients.

Immune cell regulation and cardiovascular effects of sphingosine 1-phosphate receptor agonists in rodents are mediated via distinct receptor subtypes

Sphingosine 1-phosphate (S1P) is a bioactive lysolipid with pleiotropic functions mediated through a family of G protein-coupled receptors, S1P(1,2,3,4,5). Physiological effects of S1P receptor agonists include regulation of cardiovascular function and immunosuppression via redistribution of lymphocytes from blood to secondary lymphoid organs. The phosphorylated metabolite of the immunosuppressant agent FTY720 (2-amino-2-(2-[4-octylphenyl]ethyl)-1,3-propanediol) and other phosphonate analogs with differential receptor selectivity were investigated. No significant species differences in compound potency or rank order of activity on receptors cloned from human, murine, and rat sources were observed. All synthetic analogs were high-affinity agonists on S1P(1), with IC(50) values for ligand binding between 0.3 and 14 nM. The correlation between S1P(1) receptor activation and the ED(50) for lymphocyte reduction was highly significant (p < 0.001) and lower for the other receptors. In contrast to S1P(1)-mediated effects on lymphocyte recirculation, three lines of evidence link S1P(3) receptor activity with acute toxicity and cardiovascular regulation: compound potency on S1P(3) correlated with toxicity and bradycardia; the shift in potency of phosphorylated-FTY720 for inducing lymphopenia versus bradycardia and hypertension was consistent with affinity for S1P(1) relative to S1P(3); and toxicity, bradycardia, and hypertension were absent in S1P(3)(-/-) mice. Blood pressure effects of agonists in anesthetized rats were complex, whereas hypertension was the predominant effect in conscious rats and mice. Immunolocalization of S1P(3) in rodent heart revealed abundant expression on myocytes and perivascular smooth muscle cells consistent with regulation of bradycardia and hypertension, whereas S1P(1) expression was restricted to the vascular endothelium.

Problem-based compared with traditional methods at the Faculty of Medical Sciences, University of the West Indies: a model study

The University of the West Indies (UWI) comprises three campuses located on three different islands. Two of the Campuses, Mona in Jamaica and St Augustine in Trinidad & Tobago offer full medical programmes, i.e. both basic sciences and clinical training. At Cave Hill, where basic sciences courses are not offered, students are drawn from the traditional school at Mona or the Problem Based Learning (PBL) school at St Augustine to follow a common clinical programme. After 24 months of clinical training consisting of a minimum of 12 clerkships these students take identical examinations in Medicine & Therapeutics, Surgery and Obstetrics & Gynaecology. In this paper the results of the final clinical examinations at Cave Hill for the five-year period 1995-99 have been analysed, comparing the performances of students drawn from Mona with those from St Augustine. We found that, except for a few isolated cases, there were no significant differences in the performance of the two groups of students. These results suggest that the delivery of a significant component of a basic sciences programme by a well-planned PBL system is unlikely to produce substandard students at the end of their clinical training.

A simplified cataract grading system

A simplified method for grading the presence and severity of different cataract types is needed for field use in assessment of the magnitude of the cataract problem. A cataract grading system was developed by a panel of experts with the objective of making available a simple system for use with a slit lamp to allow for the reliable grading of the most common forms of cataract by relatively inexperienced observers. Three levels, reflecting progressive severity, for grading of nuclear, cortical and posterior subcapsular (PSC) cataract were included in the classification; three standard photos were used for grading nuclear cataract. Field evaluation from four different sites indicated very good to fair interobserver agreement with the use of this system following minimal training of residents in ophthalmology at each site. Further testing of this system is warranted. The WHO simplified cataract grading system should allow for the obtaining of comparable data across countries based on field assessment of the most common forms of cataract.

Patient falls from bed and the role of bedrails in the acute care setting

The use of bedrails in preventing patient falls from bed remains highly controversial and has received only limited research attention throughout the last decade. The present study questioned the relationship between bedrail use and patient falls from bed particularly in terms of age-gender characteristics, mental status and the severity of injuries sustained. A retrospective, cross-sectional analysis was conducted of 419 patient falls occurring in an urban, acute care hospital from 1993-2000. This audit identified 136 falls from bed. It was found that for all age-gender groups the incidence of falls from bed with bedrails elevated was equal to or higher than when bedrails were not elevated. Patients in a 'non rational' state at the time of falling were significantly more likely to have fallen with the bedrails elevated (chi 2 = 19.463, p < 0.001). Whilst there was no statistically significant relationship between the position of bedrails and the severity of injuries sustained (chi 2 = 1.088, p = 0.780) the fact that there was a patient death resulting from a fall from bed over elevated bedrails was considered to be of particular clinical significance. Thus the role of bedrails as protective or safety devices was challenged and an urgent re-evaluation of current practices recommended.

Absence of a genetic association between IL-1RN and IL-1B gene polymorphisms in ulcerative colitis and Crohn disease in multiple populations from northeast England

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic inflammation of the gastrointestinal tract of unknown aetiology, phenotypically categorized into ulcerative colitis (UC) and Crohn disease (CD). Genetic factors are of considerable importance in both. The genetic relationship between IBD and the interleukin-1 receptor antagonist and interleukin-1beta genes (IL-1RN, and IL-1B, respectively) has been extensively studied. However, the quality and outcome of the genetic association studies, in particular the association with IL-1RN*2, have been variable and these associations remain controversial. The aim of the present study was to re-investigate these two candidate genes in a large series of IBD patients from a genetically homogeneous population with low levels of population admixture, and provide a definitive answer to this question.

METHODS

A total of 529 northern European Caucasoid patients with IBD (347 UC, 182 CD) and 289 racially and geographically matched healthy controls were studied. The IL-1RN and IL-1B genotypes, allele frequencies and most probable haplotypes were determined by standard PCR protocols.

RESULTS

There were no significant differences in the distributions of the IL-1RN and IL-1B genotypes, allele frequencies or haplotypes in either patient series compared to healthy controls or between clinical subsets. Genotype distribution and frequency data for allele 2 (IL-1RN*2) in particular showed no significant differences across all patient groups for all three series.

CONCLUSION

The findings of this study lead us to reject the IL-1RN*2 association with IBD.

Advancing the science and practice of reducing risks to children--a perspective from NGOs

This session focused on two areas: actions to help advance the science as well as practice of reducing rsks to children, and strategies for making partnerships between researchers, NGOs and others more productive.

Pyruvate improves cerebral metabolism during hemorrhagic shock

Pyruvate (PYR) improves cellular and organ function hypoxia and ischemia by stabilizing the reduced nicotinamide adenine dinucleotide redox state and cytosolic ATP phosphorylation potential. In this in vivo study, we evaluated the effects of intravenous pyruvate on neocortical function, indexes of the cytosolic redox state, cellular energy state, and ischemia during a prolonged (4 h) controlled arterial hemorrhage (40 mmHg) in swine. Thirty minutes after the onset of hemorrhagic shock, sodium PYR (n = 8) was infused (0.5 g x kg(-1) x h(-1)) to attain arterial levels of 5 mM. The volume and osmotic effects were matched with 10% NaCl [hypertonic saline (HTS)] (n = 8) or 0.9% NaCl [normal saline (NS)] (n = 8). During the hemorrhage protocol, the time to peak hemorrhage volume was significantly delayed in the PYR group compared with the HTS and NS groups (94 +/- 5 vs. 73 +/- 6 and 72 +/- 4 min, P < 0.05). In addition to the early onset of the decompensatory phase of hemorrhagic shock, the complete return of the hemorrhage volume during decompensatory shock resulted in the death of five and four animals, respectively, in the HTS and NS groups. In contrast, in the PYR group, reinfusion of the hemorrhage volume was slower and all animals survived the 4-h hemorrhage protocol. During hemorrhage, the PYR group also exhibited improved cerebral cortical metabolic and function status. PYR slowed and reduced the rise in neocortical microdialysis levels of adenosine, inosine, and hypoxanthine and delayed the loss of cerebral cortical biopsy ATP and phosphocreatine content. This improvement in energetic status was evident in the improved preservation of the electrocorticogram in the PYR group. PYR also prevented the eightfold increase in the excitotoxic amino acid glutamate observed in the HTS group. The findings show that PYR administered after the onset of hemorrhagic shock markedly improves cerebral metabolic and functional status for at least 4 h.

OmpA genotypic evidence for persistent ocular Chlamydia trachomatis infection in Tanzanian village women

BACKGROUND

Trachoma is still a significant problem in the developing world. Adult women are at higher risk of developing scarring and trichiasis, the potentially blinding sequelae, compared to men. In part, the higher risk may be due to more frequent infections in women because of their frequent contact with children, the main reservoir of C. trachomatis infection. However, other factors associated with infection, particularly constant infection, in adult women need to be identified.

METHODS

A group of 118 women who were infected with C. trachomatis and 118 women who were not infected, but of similar age and trachoma status, were identified in 1996 from a population-based sample of women age 16 and older from eleven villages in Kongwa, Tanzania. This group of 236 was re-contacted three years later to ascertain trachoma status and determine infection status using polymerase chain reaction-enzyme immunoassay (PCR-EIA). Positive samples at both time points were examined for serovar and genotype shift, using ompA sequencing information.

RESULTS

Of the original 236 women, 165 (70%) completed exams in 1999. Fifty-eight (35%) of the 165 women were excluded from this analysis because they received antibiotic treatment for trachoma in the six months prior to the second exam. Infection at baseline was the most important predictor of infection three years later (Age-adjusted odds ratio (95% confidence interval) 6.6 (1.8-24.4)). A total of 17 women (16%) were infected at the two examinations, and of the 15 for whom genotyping could be done, 11 (73%) were infected with the same ompA genotype at both time points. Chronically infected women were more likely to have trichiasis, scarring, and active trachoma at baseline than those never infected or infected only once. Only 41% of the chronically infected women were living in houses with infected pre-school children, but 24% were in houses with no children. Four of ten women with trichiasis developed incident corneal opacity over the three years.

CONCLUSIONS

The data provide evidence for persistence of infection in a sub-group of women. The strongest predictor of infection at follow-up was baseline infection, and most were infected with the same genotype at both time points. For women with persistent infection, at least half were either not living with children or not living with infected children, suggesting that continual re-exposure from a close family member was less likely. Chronic infection is likely related to both exposure and immunological factors, and these need to be further identified. Inclusion of women in community-based treatment programs, regardless of whether a child is present in the house, is likely to be important in preventing the progression of inflammatory trachoma and scarring to trichiasis.

A homogeneous fluorometric assay for measuring cell adhesion to immobilized ligand using V-well microtiter plates

We have developed a homogeneous high-capacity assay format for measuring integrin- and selectin-dependent cell binding to immobilized ligand using V-well microtiter plates. 2',7'-Bis(2-carboxyethyl)-5-(and-6)-carboxylfluorescence, acetoxymethylester-labeled cells are added to ligand-coated V-shaped microtiter wells. Bound cells are separated from free cells using centrifugal force to produce shear stress. Nonadherent cells accumulate in the nadir of the well and are measured using a fluorescence plate reader. Antibody or low-molecular-weight inhibitors of either the ligand or the cell surface receptor result in less cell binding, more cells in the pellet, and increased signal. The optimization and validation of the very late antigen-4/vascular cell adhesion molecule-1 assay is described in detail. We demonstrate that this assay can be rapidly adapted to measure other integrin- and selectin-mediated interactions. This assay format has several advantages over conventional assays. The centrifugal process is biologically relevant and eliminates the washing steps to remove nonadherent cells that can cause well-to-well and plate-to-plate variation. Because the assay is robust with a high signal-to-noise ratio and low variability, it is ideally suited for studying multiple parameters of cell adhesion and for high capacity screening.

A comparison of vertical force and temporal parameters produced by an in-shoe pressure measuring system and a force platform

OBJECTIVE

To investigate the ability of Pedar in-shoe system to measure vertical force accurately, by comparing it with the Kistler force platform.

DESIGN

In vivo experiment in normal subjects.

BACKGROUND

It has been suggested Pedar is highly reliable, but absolute accuracy of the system with regard to force measurement has not been comprehensively tested.

METHODS

Sampling at 99 Hz, using five healthy subjects, simultaneous data were collected barefoot, and in three types of shoes (Trainers, Oxfords, Slip-on Deck Type). Six variables obtained from the force/time curve from each footstep were compared.

RESULTS

The temporal data recorded by Pedar correlated well with that obtained using Kistler, with significant differences only in overall duration of the step in Deck shoes (P < 0.001) and Oxford shoes (P < 0.01), and peak to peak barefoot (P < 0.01). Pedar recorded a lower first peak force and mid-peak force in all cases (P < 0.001). However, the magnitude of the 2nd peak force recorded by both systems was significantly different only in Trainers (P < 0.05) and Oxford shoes (P < 0.001). The impulse data obtained with Oxford shoes was not significantly different, although barefoot, Trainers and Deck shoes were significantly lower (P < 0.001) for Pedar.

CONCLUSIONS

In most cases, comparison of data recorded by the two systems provided good evidence for the accuracy and reliability of temporal measurements and second peak force measurements taken with the Pedar in-shoe system. Relevance. In-shoe pressure data provides evidence for clinical decisions if the systems utilised are proven to be valid, repeatable and accurate. Comparison with an established force platform enables some assessment of these factors.

Susceptibility markers in colorectal cancer

Many susceptibility factors contribute to an individual's risk of developing colorectal cancer. Family history of colorectal cancer (particularly with early age of onset), maleness and increasing age are all factors associated with increasing risk. About three quarters of colorectal cancers are thought to be due to somatic mutations, and both high- and low-penetrance predisposing genes contribute to the remaining quarter of cases. Many of the highly penetrant dominant genes are known, but others remain to be identified. Describing the contribution of individual genes is likely to be very complex, as some modify the impact of other genes and other environmental factors rather than incurring a direct, easily attributable effect. The two dominant predisposing syndromes are familial adenomatous polyposis and Lynch syndrome, the first due to a mutant tumour-suppressor gene APC, and the second due to mutations in a number of genes responsible for mismatch repair in DNA at cell division. Establishing genetic susceptibility for colorectal cancer will soon be possible, and could save lives by allowing targetting of screening and the encouragement of preventive behaviours. However, there will always be a risk of making healthy people "sick" through the identification of predisposing genes, and there are many potential ways by which a gene carrier may be stigmatized by society, insurance companies and employers.

Effect of low-dose estrogen on hemodynamic response to stress

OBJECTIVE

To determine the effect of low-dose esterified estrogen on hemodynamic responses at rest and during stress in postmenopausal women, and to compare the changes with those seen with conjugated equine estrogen.

DESIGN

Open-label study of esterified estrogen compared with a double-blind, placebo-controlled investigation of conjugated equine estrogen.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Postmenopausal women with normal endometrium, not currently using hormones.

INTERVENTION(S)

Cardiovascular parameters at rest and in response to stressors were assessed in 11 postmenopausal women before and 6 months after receiving 0.3 mg esterified estrogen. Responses were compared with 42 postmenopausal women randomized to 0.625 mg conjugated equine estrogen or placebo.

MAIN OUTCOME MEASURE(S)

Changes in mean arterial pressure (MAP) and vascular resistance index from before to after treatment.

RESULT(S)

At rest, MAP increased 3.3 +/- 1.5 mm Hg (+/-SD) in the placebo group, while declining 2.3 +/- 1.5 mm Hg and 4.8 +/- 1.4 mm Hg, respectively, in the esterified estrogen and conjugated equine estrogen groups after treatment. During mental stressors, MAP dropped significantly in both treatment groups. At rest and during mental stressors, vascular resistance index decreased with estrogen treatment.

CONCLUSION(S)

Low-dose esterified estrogen improved hemodynamic patterns similar to standard doses of conjugated equine estrogen in postmenopausal women.

Guidelines for molecular genetic detection of susceptibility to malignant hyperthermia

Malignant hyperthermia (MH) is a potentially fatal pharmacogenetic disease triggered by several anaesthetic agents. The in vitro muscle contracture test (IVCT) is the standard test to establish an individual's risk of susceptibility to MH. Clinical practitioners and geneticists of the European MH Group have agreed on the present guidelines for the detection of MH susceptibility using molecular genetic techniques and/or IVCT to predict the risk of MH.

Prevention of blindness and priorities for the future

The impact of visual loss has profound implications for the person affected and society as a whole. The majority of blind people live in developing countries, and generally, their blindness could have been avoided or cured. Given the current predictions that the number of blind people worldwide will roughly double by the year 2020, it is clear that there is no room for complacency. As the world's population increases and as a greater proportion survives into late adulthood, so the number of people with visual loss will inexorably rise. Given the success of programmes in combating the most common causes of blindness (infectious diseases and malnutrition) which generally affect the young, and the projected demographic shift, age-related eye disease will become increasingly prevalent. Effective preventive measures for these diseases can only be established as more is known about their etiology. As the longevity of the world's population increases, the visual requirements at the workplace are also changing. People with low vision may be at a disadvantage in many common activities, and may face unemployment--particularly in technological societies. The definition of blindness needs to be rethought, to ensure that people with "economic" blindness are not forgotten. Efforts should be made to recognize and treat those affected at an early stage, for the benefit of the individual and society.

Circadian Rhythm, Shiftworks and You!

Chronobiological knowledge is increasing and the relationship between this knowledge and shiftwork is becoming clearer. This, in turn, is highlighting a need to facilitate a mix of permanent (day, evening and night) and rotational shift systems within individual wards or units. Is it perhaps time to allow greater flexibility in how individual nurses deal with the profession's need to care for patients throughout the 24 hour period? This review will focus on the 24 hour day-night or circadian rhythms and the consequences of the disruption of these rhythms as nurses undertake shiftwork and other activities which demand efficient functioning at times when an individual's circadian rhythms are expecting them to be at rest. As disruption of these rhythms is essentially unavoidable when 24 hour care is required, the choice becomes one of determining a preference for tolerable rhythm desynchrony and shorter more frequently occurring episodes of night work, or some degree of rhythm synchrony and adaptation during slightly longer but less frequent episodes of rhythm disruption.

Bone mineral and lean tissue loss after long duration space flight

The loss of bone and muscle is a major concern for long duration space flight. In December of 1989, we established a collaboration with Russian colleagues to determine the bone and lean tissue changes in cosmonauts before and after flights on the Mir space station lasting 4-14.4 months. Eighteen crew members received a lumbar spine and hip DEXA scan (Hologic 1000W) before and after flight; 17 crew members received an additional whole body scan. All results were expressed as percent change from baseline per month of flight in order to account for the different flight times. The pre-and post-flight data were analyzed using Hotelling's T(2) for 3 groups of variables: spine, neck of femur, trochanter; whole body BMD and subregions; lean (total, legs, arms) and fat (total only). A paired t-test was used as a follow-up to the Hotelling's T(2) to identify the individual measurements that were significantly different. These data define the rate and extent of bone and lean tissue loss during long duration space flight and indicate that the current in-flight exercise program is not sufficient to completely ameliorate bone and muscle loss during weightlessness.

Identification of novel genes in late-onset Alzheimer's disease

Four genes affecting Alzheimer's Disease (AD)(AP, PS1, PS2, and APOE) have been identified and a fifth potential gene localized to chromosome 12. Collectively, these genes explain at most half of the genetic effect in AD. Understanding the genetics of AD is critical to developing new treatments. The quest to find the remaining AD genes led us to undertake a large genomic screen using over 466 families (730 affected sibpairs) in late-onset AD. In conjunction with this increase in power, we initiated several novel approaches to identify potential AD-related genes. This included stratification of the data into an autopsy-confirmed subset of 199 AD families. Each of these targeted analyses resulted in the identification of novel regions containing potential AD genetic risk factors. Our most significant finding was on chromosome 9 in the autopsy-confirmed subset where we obtained an MLS of 4.31. These approaches, together with new methodologies such as conditional linkage analysis, generalized family-based association tests (PDT), and a new generation of genetic markers (SNPs), opens the door for additional AD gene discovery. Such strategies are necessary if we are to understand the subtle and complex threads that, woven together, create the intricate tapestry of AD.

A comparison of vertical force and temporal parameters produced by an in-shoe pressure measuring system and a force platform

OBJECTIVE

To investigate the ability of Pedar in-shoe system to measure vertical force accurately, by comparing it with the Kistler force platform.

DESIGN

In vivo experiment in normal subjects.

BACKGROUND

It has been suggested Pedar is highly reliable, but absolute accuracy of the system with regard to force measurement has not been comprehensively tested.

METHODS

Sampling at 99 Hz, using five healthy subjects, simultaneous data were collected barefoot, and in three types of shoes (Trainers, Oxfords, Slip-on Deck Type). Six variables obtained from the force/time curve from each footstep were compared.

RESULTS

The temporal data recorded by Pedar correlated well with that obtained using Kistler, with significant differences only in overall duration of the step in Deck shoes (P<0. 001) and Oxford shoes (P<0.01), and peak to peak barefoot (P<0.01). Pedar recorded a lower first peak force and mid-peak force in all cases (P<0.001). However, the magnitude of the 2nd peak force recorded by both systems was significantly different only in Trainers (P<0.05) and Oxford shoes (P<0.001). The impulse data obtained with Oxford shoes was not significantly different, although barefoot, Trainers and Deck shoes were significantly lower (P<0.001) for Pedar.

CONCLUSIONS

In most cases, comparison of data recorded by the two systems provided good evidence for the accuracy and reliability of temporal measurements and second peak force measurements taken with the Pedar in-shoe system. Relevance In-shoe pressure data provides evidence for clinical decisions if the systems utilised are proven to be valid, repeatable and accurate. Comparison with an established force platform enables some assessment of these factors.